Provider Demographics
NPI:1376019257
Name:MORTON, MALLORY (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MORTON
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 E GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-4062
Mailing Address - Country:US
Mailing Address - Phone:318-471-8898
Mailing Address - Fax:
Practice Address - Street 1:1102 N PINE RD
Practice Address - Street 2:
Practice Address - City:OLLA
Practice Address - State:LA
Practice Address - Zip Code:71465-4804
Practice Address - Country:US
Practice Address - Phone:318-495-3131
Practice Address - Fax:318-495-3229
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2588133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered